A STUDY OF PREVALENCE AND ASSOCIATION OF HYPOTHYROIDISM AND SERUM LIPID PROFILE IN DIAGNOSED GALL STONE DISEASE AT TERTIARY CARE HOSPITAL Dissertation Submitted to THE TAMILNADU Dr. M.G.R MEDICAL UNIVERSITY In partial fulfilment of the requirements for the award of the degree of M.S. GENERAL SURGERY Branch I MAY 2019 CERTIFICATE I This is to certify that this dissertation entitled “A Study of Prevalence and Association of Hypothyroidism and Serum Lipid profile in diagnosed Gall Stone Disease at Tertiary Care Hospital” is a bonafide record of the work done by Dr. Soumya Shree under the supervision and guidance of Dr. R. Maheswari, M.S., Professor, Department of General Surgery, Sree Mookambika Institute of Medical Sciences, Kulasekharam. This is submitted in partial fulfilment of the requirement of The Tamilnadu Dr. M.G.R. Medical University, Chennai for the award of M.S. Degree in General Surgery. Dr. R. Maheswari, M.S., Dr. S. Soundara Rajan, M.S., [Guide] Professor & HOD, Professor, Department Of General Surgery Department Of General Surgery Sree Mookambika Institute of Sree Mookambika Institute of Medical Sciences [SMIMS] Medical Sciences [SMIMS] Kulasekharam, K.K District, Kulasekharam, K.K District, Tamil Nadu -629161 Tamil Nadu -629161 Dr. Rema V. Nair, M.D., D.G.O., [Director] Sree Mookambika Institute of Medical Sciences [SMIMS] Kulasekharam, K.K District, Tamil Nadu -629161 CERTIFICATE II This is to certify that this dissertation work “A Study of Prevalence and Association of Hypothyroidism and Serum Lipid profile in diagnosed Gall Stone Disease at Tertiary Care Hospital” of the candidate Dr. Soumya Shree with registration Number 221611703 for the award of M.S. in the branch of General Surgery [Branch-I]. I, personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 4 percentage of plagiarism in the dissertation. Guide & Supervisor sign with Seal. Dr. R. Maheswari, M.S., DECLARATION In the following pages is presented a consolidated report of the study “A Study of Prevalence and Association of Hypothyroidism and Serum Lipid profile in diagnosed Gall Stone Disease at Tertiary Care Hospital” done in the Department of General Surgery at Sree Mookambika Institute of Medical Sciences, Kulasekharam. This thesis is submitted to the Dr. M.G.R. Medical University, Chennai in partial fulfilment of the rules and regulations for the award of MS Degree in General Surgery. Dr Soumya Shree Junior Resident Department of General Surgery Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari District. Tamil Nadu 629161. ACKNOWLEDGEMENT With overwhelming thanks and gratitude, I submit this effort to God Almighty for being my constant support and strength throughout the course of the study. I humbly thank my father Col. S.K. Singhal, my loving mother Mrs. Neelam Singhal, and my beloved sister Ms. Priya Shree for their continuous encouragement and guidance. I extend my sincerest gratitude to my guide Dr. Maheswari, and my Head of Department General Surgery Dr. S. Soundara Rajan, for their suggestions, critical view and help throughout the study. I, also express my gratitude to Dr. Rema. V. Nair, Director, Dr. C.K. Velayuthan Nair, Chairman and Principal Dr. Padmakumar for providing the necessary facilities for the successful completion of my study. I thank my friends who have been a source of constant encouragement and help in completing my study. Last but not the least, I wish to express my heartfelt gratitude to all the patients who agreed to participate in the study. LIST OF CONTENTS Sl. No. Contents Page No 1. Introduction 1 2. Aim of the Study 3 3. Hypothesis and Scientific Justification 4 4. Review of Literature 5 5. Materials and Methods 52 6. Analysis and Interpretations 55 7. Discussion 66 8. Conclusion 72 9. Summary 74 10. Recommendations 75 11. Limitation of the Study 76 12 Bibliography 77 13 Appendix i-ix LIST OF TABLES Sl. No Tables Page No 1 Age distribution 56 2 Gender distribution 57 3 Normal reference values 59 4 T3 Levels 60 5 T4 Levels 61 6 FT4 Levels 62 7 TSH Levels 63 8 Symptom of hypothyroidism 64 9 Correlation between high TSH and FLP 66 10 Comparison of sex distribution 66 11 Comparison of age distribution 67 12 Comparison study of thyroid profile 68 13 Comparison between age group having high serum TSH 70 LIST OF FIGURES Sl. No Figures Page No 1 Mechanism of action of Thyroid Hormone 9 2 Regulation of Thyroid hormone Synthesis 14 3 Calot triangle 22 4 Sphincter of Oddi 23 5 Cholesterol stones 32 6 Pigment stones 32 7 Mixed stones 33 8 Plain XRAY abdomen showing gallstones 41 9 USG abdomen showing gallstones 41 Oral cholecystography showing gallstones as a filling 10 42 defect 11 Laparoscopic versus open cholecystectomy 46 12 Intraoperative steps in laparoscopic choloecystectomy 47 13 Effect of thyroid hormone on formation of gallstones 49 14 Effect of thyroid hormone on cholesterol metabolism 50 15 Thyroid and cholesterol metabolism 51 16 Gender distribution 57 17 T3 Levels 60 18 T4 Levels 61 19 FT4 Levels 62 20 TSH Levels 63 21 Symptom of hypothyroidism 64 22 Comparison of sex distribution 66 23 Age comparison between different studies 67 24 Comparison study of thyroid profile 69 25 Comparison of age group having high TSH 70 ABBREVIATIONS GB - Gall Bladder CBD - Common Bile Duct SO - Sphincter of Oddi CCK - Cholecystokinin USG - Ultrasonogram CECT - Contrast Enhanced Computed Tomography MRCP - Magnetic Resonance Cholangio Pancreaticography ERCP - Endoscopic Retrograde Cholangiopancreaticography PTC - Percutaneous Transhepatic Cholangiography TSH - Thyroid Stimulating Hormone TH - Thyroid Hormones TR - Intranuclear Thyroid Receptors LDL - Low Density Lipoproteins HDL - High Density Lipoproteins FLP - Fasting Lipid Profile ABSTRACT ABSTRACT Title: A study of prevalence and association of hypothyroidism and serum lipid profile in diagnosed gall stone disease at tertiary care hospital. Introduction: Thyroid disorders are one of the most common endocrinology disorders in the world. Recently, it has been found that hypothyroidism causes low bile flow and sphincter of Oddi dysfunction leading to gallstone diseases. Also it has been found that patients who are hypothyroid show cholesterol metabolism disturbances. Therefore this study is being done to substantiate need of thyroid function tests in gall stone disease patients and to further evaluate their risk of developing cardiovascular diseases by testing their lipid profile. Aims: to estimate the prevalence of hypothyroidism in diagnosed case of gall stone diseases. Also to estimate serum lipid profile in gall stone diseased patients who are hypothyroid. Materials and Method: this is an observational prospective study. Method of sampling was purposive. 100 patients with gall stone disease were evaluated and thyroid function and lipid profile tests were performed after taking written informed consent. Results: In our study of 100 cases, age of selected patients were between 24-75 years. Out of this 64% were females and rest 36% were males. Thyroid function tests were performed and 25% showed high TSH and rest 75% showed normal TSH levels. 98% patients presented with pain in right hypochondrium and histopathology showed 90% cases having gallstones. There was also a positive correlation between HDL and TSH, Total cholesterol and TSH. Conclusion: Evaluation of thyroid functions and lipid profile should be done for patients who are diagnosed with gall stone diseases. Keywords – Hypothyroidism, Cholelithiasis, Gallbladder, HDL INTRODUCTION Introduction INTRODUCTION Gall stone diseases are one of most common diseases affecting gastro intestinal tract. The pathogenesis of gallstones is a complex process and involves many factors altering cholesterol mechanism. It varies along the age, gender, geography, food habits, sedentary life style and obesity. Most gallstones are asymptomatic but the disease can contribute to high health care cost and rarely have life threatening consequences. Gall stones are of three types – cholesterol, pigment or mixed. They can be single or multiple, small or large, radio opaque or radiolucent. Thyroid diseases are, in general, amongst the commonest endocrinology disorders. The most common conditions include hyperthyroid states or hypothyroid states. The most common thyroid conditions are due to abnormal production of thyroid hormones. For decades now, it has been discussed, whether thyroid disorders can cause gallstones. Low bile flow and sphincter of Oddi dysfunction are regarded as important factors that promote gall stone formation. There have been several explanations for a relationship between hypothyroidism and gallstone disease. The explanations include: 1) The sphincter of Oddi expresses thyroid hormone receptors (β1 and β2) and thyroxine (T4) has a direct pro-relaxing effect on the sphincter, causing both reduced bile flow and sphincter of Oddi dysfunction2 Page 1 Introduction 2) Secondly, sphincter of Oddi function disturbance prevents normal bile flow, hence enhancing the probability of common bile duct (CBD) stone formation. 3) Lastly, due to the known link between thyroid failure and disturbances of lipid metabolism, there is a consequent change in composition of bile. Thyroid hormone also exhibits effect on liver functions including stimulation of enzymes regulating lipogenesis, lipolysis and oxidative processes. It also regulates gene expression for gluconeogenesis, lipogenesis, insulin